16 year old with Viral Pyrexia

Unit 6 admission

A 16 year old male came to the opd with c/o 

Fever since 5 days

Vomitings 5 days back (7 to 8 episodes)

Fever- low grade, intermittent, not associated with chills and rigor, relieved on medications)

Vomitings- non projectile, bilious, food particles as content

No h/o pain abdomen,loose stools

No h/o cold,cough,sob

Outside platelet count was 73,000(9/10/21)

So they brought him here to our hsptl

PAST HISTORY:

No h/o DM, HTN, asthma, epilepsy, TB

PERSONAL HISTORY

Appetite-decreased

Regular bowel and bladder movements

No addictions

GENERAL EXAMINATION : 

Patient is conscious, coherent and cooperative  

No pallor, Icterus, cyanosis, clubbing, lymphadenopathy

VITALS : 

Temp: 99F

PR: 86bpm 

BP: 100/80 mm hg 

RR: 20 cpm  

Spo2 - 99%

CVS : 

S1, S2 heard , No murmurs 

RS : 

Position of trachea: central 

BAE present

PER ABDOMEN: Soft

Mild tenderness present in umbilical region

Bowel sounds +

CNS: 

Patient is Conscious ,oriented to time,place and person 

HMF -intact 

Motor & sensory system: normal 

Reflexes: present 

Cranial nerves: intact 

No meningeal signs 

PROVISIONAL DIAGNOSIS-

Viral pyrexia with thrombocytopenia

INVESTIGATIONS

Soap notes DAY 1

AMC BED 

S- no fresh complaints

O- 

Bp- 110/80mm hg

Pr- 74/min

Temp-Afebrile

Cvs-S1,S2 +

Rs- bae+ , NVBS , clear

P/A- soft, nontender

Bs+

Cns- hmf intact

A- viral pyrexia with thrombocytopenia

P- 

1.IVF 1 unit of NS and RL IV @100ml/ hr

2.INJ PCM IV

3.Tab Pan 40mg IV OD BBF

4. Bp/pr/temp charting 8th hrly

5.inform Sos

Soap notes DAY 2

AMC BED 

S- no fresh complaints

O- 

Bp- 100/70mm hg

Pr- 72/min

Temp-Afebrile

Cvs-S1,S2 +

Rs- bae+ , NVBS , clear

P/A- soft, nontender

Bs+

Cns- hmf intact

A- viral pyrexia with thrombocytopenia

P

1.IVF 1 unit of NS and RL IV @100ml/ hr

2.Tab PCM 650MG/ PO SOS

3. Bp/pr/temp charting 8th hrly